Respondents
Eight CR programs were identified in Arab countries: 4 in Gulf countries (1 in Bahrain
[HIC], 1 in Qatar [HIC], and 2 in United Arab Emirates [HIC]) and 4 in Africa (2 in
Egypt [MIC] 35], 1 in Algeria [MIC], and 1 in Tunisia [MIC]). Five programs responded (62.5 % response
rate): 1 in Bahrain, 1 in Egypt, 1 in Qatar, and 2 in United Arab Emirates. The CR
programs in Tunisia and Algeria could not be reached because the email addresses of
the corresponding authors listed in a conference abstract and a French-translated
abstract, respectively, were invalid. With regard to Canadian CR programs, there were
128 unique programs in the directory validated through the emails and calls. Thirty-nine
programs responded (30.5 % response rate).
Respondents from Arab countries were CR coordinators (?=?2), a manager, a supervisor and a cardiologist; whereas, respondents from Canada
were most frequently CR coordinators (?=?14; 35.9 %), managers (?=?12; 30.8 %), and infrequently directors (?=?1; 2.6 %) and supervisors (?=?1; 2.6 %). Other (?=?11; 28.2 %) respondents were clinical nurse leaders, exercise therapists and physiotherapists.
Program characteristics
CR program characteristics are presented in Table 1. CR program duration in Arab countries was 3 months. In Canada, 26 (66.6 %) respondents
reported a program duration of 3–6 months, 5 (12.8 %) reported 12 months, 4 (10.3
%) reported 3 months and 4 (10.3 %) reported 7–12 months. Patients attended an average
of 2.3?±?1.5 (mean?±?standard deviation) sessions per week in Arab countries and 2.3?±?1.0
sessions per week in Canada. Only programs in Canada offered alternative delivery
models, specifically 11 (28.2 %) offered community-based programs and 1 (2.6 %) home-based.
However, 60 % of Arab programs offered women-only classes (Table 2).
Table 1. Characteristics of Cardiac Rehabilitations Programs
Table 2. Assessment of Risk Factors and Components Offered
Risk factors assessed by CR programs are reported in Table 2. Risk factors assessed were highly consistent in both Arab countries and Canada,
with blood pressure, body mass index, tobacco use, lipids, blood glucose, and harmful
use of alcohol being most consistently assessed (?80 %). CR programs in Arab countries
did appear to assess for sleep apnea more often than Canadian programs.
CR components offered are also reported in Table 2. Patient education, initial assessment, exercise prescription and nutrition counselling
were most consistently offered in both Arab and Canadian programs (?80 %). However,
physical activity counselling, supervised exercise training, communication with primary
care, end of program re-assessment, depression screening, and exercise stress testing
were reported less frequently in Arab than in Canadian programs. While caution is
warranted due to the low number of programs in Arab countries, programs in these countries
more often offered prescription or titration of secondary preventive medications,
psychological counselling and women-only classes than programs in Canada. Having a
link to exercise programs within the community was reported for only one (20 %) Arab
CR program, yet was available in 25 (69.4 %) programs in Canada.
CR healthcare providers and their training
In 50 % of programs both in Canada and Arab countries, physicians (cardiologists
or specialists in internal medicine) held the overall responsibility for CR delivery
(Table 3). Nurses were most routinely present during exercise sessions in Canadian and Arabic
programs. Notably, there were fewer healthcare specialties represented in Arabic than
in Canada’s CR programs (5 versus 10 specialties), with no psychologists, dietitians,
kinesiologists or pharmacists on staff. In 4 (80.0 %) CR programs in the Arab countries,
respondents reported their program staff had cardiopulmonary resuscitation training,
versus 37 (94.9 %) programs in Canada.
Table 3. Type of Cardiac Rehabilitation Professionals
All respondents from the Arab countries indicated the absence of any formal education
or training programs for healthcare professionals regarding delivering CR services
in their country. Several sources for formal education or training programs were reported
by 16 Canadian respondents. The training programs reported were offered by the American
College of Sports Medicine (?=?4), the Canadian Association of Cardiovascular Prevention and Rehabilitation, and
by some universities and colleges.
When participants were asked to list educational materials (e.g., textbooks, guidelines)
which were most used/useful for delivering CR in their country, only one (20.0 %)
Arabic respondent listed a source, which was the Canadian CR Guidelines. Two (40.0
%) Arabic respondents and 37 (94.9 %) Canadian respondents stated that their regional
Society / Association of Cardiology addresses the role of CR for the secondary prevention
of CVD in its Position Statements or Guidelines.
Patients entering CR
Respondents estimated that 31.2?±?32.5 % of patients in Arab countries and 37.4?±?26.6
% of patients in Canada had been screened for CVD risk factors prior to experiencing
the cardiac event or procedure that led them to be referred to CR. They also estimated
21.1?±?22.7 % of CR participants in the Arab CR programs, and 24.3?±?26.6 % of CR
participants in Canada’s, engaged in 150 minutes of moderate to vigorous-intensity
physical activity each week prior to CR (i.e., guideline recommendation 16]). The average time to start a CR program following discharge from the hospital was
estimated as 4.4?±?4.2 weeks in Arab countries, and 5.8?±?3.9 weeks in Canada.
CR access and barriers
Respondent perceptions of barriers to CR participation are shown in Table 4. Lack of human resources and lack of space were equally perceived as the greatest
barriers to participation in Arab countries. “Other†(?=?2) responses from Arabic respondents were lack of training and technical guidelines.
In Canada, lack of financial resources, followed by lack of human resources, were
perceived as the greatest barriers. “Other†(?=?2) responses from Canadian respondents were lack of patient awareness and lack
of administrative support.
Table 4. Barriers to CR Participation, by Country
Subpopulations which were perceived to have less access to CR are shown in Table 4. Rural patients and those of low economic status were most often reported by Canadian
respondents; patients of low economic status, with musculoskeletal conditions, disability,
and women were most often reported by Arab respondents.
Respondents were asked to estimate the percentage of patients who leave the CR program
prior to completion. Respondents in Arab countries estimated an average of 36.8?±?14.9
%, while Canadian respondents estimated 22.3?±?15.5 %. Perceived reasons for patient
failure to complete CR programs are also presented in Table 4. Patient non-compliance followed by return-to-work were the most-often reported reasons
by respondents in Arab countries and Canada. Financial reasons were also prominent
in Arab countries, as were transportation barriers in Canada. Twelve (30.8 %) Canadian
respondents reported another reason for non-completion, namely illness or medical
issues; no Arabic respondents provided another reason.
CR capacity
Respondents were asked to estimate the number of CR programs available in their country,
where the 5 response options ranged from 0–20 to 500. Four (80 %) respondents from
Arab countries estimated 0–20 programs. For Canada, 12 (30.8 %) respondents reported
101–250 programs, and 6 (15.4 %) respondents estimated 21–100 programs. For this and
the below questions, other respondents selected “I do not knowâ€.
Respondents were asked to estimate the number of patients that attended CR in their
country in the last year, where the 5 response options ranged from 0–350 to 1000.
More than half of respondents (?=?3; 60.0 %) in the Arab countries estimated that in 2013, 0–350 patients attended
outpatient CR. About one-third of the Canadian respondents (?=?14; 35.9 %) estimated over 10,000 patients attended outpatient CR. Respondents
were asked to estimate the percentage of all diagnostically-eligible patients that
attended outpatient CR nationally in 2013, where the 5 response options ranged from
0–10 % to 60 %. For the Arab countries, 3 (60.0 %) respondents estimated 11–25 %
of eligible patients, and 1 (20.0 %) respondent estimated 0–10 %. For Canada, 13 (33.3
%) respondents estimated 11–25 %, 11 (28.2 %) respondents estimated 26–40 %, 5 (12.8
%) were unsure, and the rest estimated??41 % of the eligible patients.
Estimates of CR capacity are presented in Table 5. As shown, CR programs in Canada are serving more patients per year, yet less than
they have capacity to serve. This situation is opposite in Arab countries, where they
report treating more patients than they have the capacity to serve. In Arab countries,
the mean number of patients/session served in CR programs was less than that of the
Canadian CR, but the median was higher in Canada. Arab programs have a much lower
staff-to-patient ratio than Canadian ones (1:1.5 vs. 1:5.0, respectively). All respondents
(?=?5; 100 %) from CR programs in Arab countries reported that they have dedicated
space for CR, whereas 31 (81.6 %) respondents from Canadian programs reported having
such dedicated space.
Table 5. Cardiac Rehabilitation Capacity
To increase CR program capacity, 2 (40 %) Arab respondents suggested having support
from decision-makers, 1 (20 %) reported increasing program staffing, 1 (20 %) reported
spending on equipment, and 1 (20 %) reported additional training. For Canada, of the
27 who responded to this open-ended question, 12 (44.4 %) reported greater staffing,
7 (25.9 %) reported additional space, 6 (22.2 %) reported additional funding, and
2 (7.4 %) suggested other resources.
CR funding and expenses
Respondents were asked about reimbursement and funding models for their services.
In Arab countries, 2 respondents (40 %) each reported the following type of payment
for CR services: government, the patient, and private health insurance. In Canada,
CR services were most often paid for by the hospital (?=?18, 48.6 %; which is funded by government), government (?=?17, 44.7 %), patients (?=?13, 34.2 %), and private health insurance (?=?4, 10.8 %),
Ratings of the expense associated with delivering CR are shown in Table 6. As shown, the most expensive elements reported by Arab respondents were exercise
equipment, equipment / supplies for risk assessment, exercise stress testing, and
front-line personnel. In Canada, the most expensive elements were front-line personnel,
exercise stress testing, blood collection and lipid testing, followed by exercise
equipment.
Table 6. Mean Perceived Expense (± standard deviation) Associated with CR Components
a